I. A coronary chronic total occlusion (CTO) case performed by Zaheed Tai, DO.

A 74-year-old female presents with a history of multi-vessel coronary artery disease, diabetes, hyperlipidemia, hypertension, and renal insufficiency. She had a catheterization in January 2015 and was deemed a non-surgical candidate.She subsequently underwent emergent revascularization after a ventricular fibrillation arrest, with percutaneous coronary intervention (PCI) of the left anterior descending coronary artery (LAD) performed by another physician. She has a chronic total occlusion (CTO) of the right coronary artery (RCA), which has been staged secondary to renal insufficiency. 

She has left ventricular (LV) dysfunction with viable myocardium in the inferior wall and ongoing angina. The plan is to perform a staged intervention of the right coronary artery (RCA) chronic total occlusion (CTO).

The patient’s right radial artery was prepped and draped in sterile fashion using Doppler guidance. The right radial artery was accessed, but the wire could not be passed, and femoral access was chosen. The right groin was accessed with a micropuncture kit. A Glidesheath Slender (Terumo) was placed and upsized to a 7 French (Fr) 45cm Destination sheath (Terumo). 

The left groin was accessed with a micropuncture sheath and a 5Fr sheath was inserted, then upsized to a 6Fr sheath. From the right groin, a hockey stick catheter with side holes was used to engage the right coronary system, since initial use of a hockey stick catheter without side holes resulted in pressure dampening. From the left groin, a Judkins left (JL) 4Fr guide was used to engage the left system. Angiographically (Figure 2), the left main was found to be patent, with patent stents in the proximal and mid LAD. There was a patent T-stent in the diagonal as well. There was evidence of left-to-right collaterals. The RCA was 100% occluded in the mid portion and reconstituted distally via some right-to-right and left-to-right collaterals.

Heparin was administered and a Runthrough wire (Terumo) was advanced into the proximal RCA with an .014-inch Quick-Cross catheter (Spectranetics). A super support catheter, the MultiCross (Roxwood Medical), was deployed into the mid RCA (Figures 1A-3). This catheter has three separate .014-inch wire lumens. Using wire escalation, an Asahi Fielder XT wire (Abbott Vascular) was used to cross into the distal RCA. Confirmation was achieved via collateral injection (Figure 4) and the wire was advanced into the patent ductus arteriosus (PDA). The MultiCross catheter was removed. An 0.9mm laser (Spectranetics) was used to performed laser atherectomy of the vessel (Figure 5). Following laser atherectomy lasting approximately 40 seconds, balloon angioplasty was performed with a 2.5 x 30mm balloon. A 2.5 x 38mm Promus Premier stent (Boston Scientific) was deployed. It did not cover the entire lesion. The goal was to cover the more proximal lesion, and the RCA did have a 40% to 50% stenosis prior to the CTO. Intravascular ultrasound (IVUS) demonstrated that it was a >70% lesion, clinically more significant, and therefore a 3.0 x 23mm, instead of a 3.0 x 12mm, Promus Premier stent was used to cover the entire area of disease. By IVUS, the proximal RCA did not show disease. An eccentric piece of calcium could be seen, but the vessel was 4.0mm without any significant obstruction. After deployment of the second stent, intracoronary nitroglycerin was administered and angiography revealed TIMI-3 flow (Figure 6). 

A distal, focal 70-80% lesion was present prior to the bifurcation, not seen initially due to poor filling of the distal vessel. Intervention was chosen in order to provide adequate distal runoff. A 2.25 x 12mm Promus Premier stent was placed, but led to an edge dissection, given the diffuse nature of the vessel. To cover the gap between the 2.5mm and the 2.25mm stent, a 2.5 x 28mm Promus Premier stent was placed and subsequently post dilated with a 2.5mm Quantum balloon (Boston Scientific) at high pressure. Final angiography demonstrated TIMI-3 flow, without dissection, perforation, or embolization. All stents were appropriately sized according to IVUS measurement of the vessel. Wires were then removed and orthogonal views revealed TIMI-3 flow without dissection, perforation, or embolization (Figure 7). The patient tolerated the procedure well. The guide was removed, a TR Band (Terumo) was placed on the radial site, and Perclose (Abbott Vascular) was used to close both groins.

II. A peripheral CTO case performed by Kaylan K. Veerina, MD.

The patient is a 70-year-old male with a history of peripheral vascular disease and claudication. After initial angiography, an intervention to the anterior tibial artery was chosen. 

The patient was prepped and draped in a sterile fashion. Right femoral access was obtained using Seldinger technique and a 6 x 45cm, 6Fr sheath was placed. Angiographic finding with runoff demonstrated evidence of diffuse, atherosclerotic, calcified disease of the superficial femoral artery, which is patent, with straight-line flow to the popliteal. Distal runoff showed evidence of an occluded posterior tibial artery and peroneal artery. The anterior tibial artery showed a flush occlusion proximally with mid reconstitution of the anterior tibial and sluggish flow to the foot. 

A .014–inch Regalia wire (tip load 1.0 gram) (Asahi Intecc) was advanced. The MultiCross support catheter was advanced to the CTO and deployed. An Astato 20 wire (20 gram tip load) (Asahi Intecc) was advanced through one of the lumens of the MultiCross catheter, was unsuccessful in this attempt to cross, and removed. Another lumen of the MultiCross catheter was used, with successful entry to the proximal cap of the CTO (Figures 8-9). The wire was advanced through the CTO proximally and passed distally through the anterior tibial artery. Distally, the MultiCross was exchanged for a crossing catheter, and the Astato 20 was exchanged for a Viper wire (CSI). Orbital atherectomy was performed with a 1.25mm micro crown (CSI) at medium and high speeds. Adjunctive angioplasty with prolonged inflations at nominal pressure was performed using a 4 x 200mm Fox SV balloon (Abbott Vascular). Angiography demonstrated excellent expansion of the lesion without recoil, dissection, perforation or embolization. There was straight-line flow to the anterior tibial and dorsalis pedis arteries.

Dr. Kaylan Veerina notes, “This case presented an extremely challenging anterior tibial artery CTO with only a slight sign of the takeoff.  The MultiCross catheter was a vital in our successful crossing of the CTO and allowed us to remain in the true lumen. 

By doing so, all of our treatment options remain available for our patients during these most difficult cases.This super support catheter provides true clinical value for my patients and practice.”     

Orlando Marrero, RCIS, MBA, can be contacted at orlm8597@icloud.com. 

Dr. Zaheed Tai can be contacted at zaheedtai@gmail.com. 

Dr. Kaylan Veerina can be contacted at kalyan.veerina@cardio.com.

Disclosures: Orlando Marrero reports he works for Mercator MedSystems and is a consultant for Boston Scientific. 

Dr. Zaheed Tai reports the following: Terumo (proctor for transradial course),Spectranetics (proctor for laser course, speaker, advisory board member), The Medicines Company (speakers bureau). Dr. Kaylan Veerina reports no conflicts of interest regarding the content herein.